MEDICAL JURISPRUDENCE
Fatal Period.— Death occurred in four hours and-a-half from a dose of 90 to 105
grains.™ Death has also occurred in twenty hours and has been delayed for six to seven
days.
Treatment.— Eliminate the poison from the stomach by washing it out thoroughly
with warm water in which animal charcoal is suspended, and then introduce about
\ an ounce of sodium sulphate. Wash out the colon and repeat it after twelve
hours. Keep the patient warm. Remove any accumulated mucus from the throat and
establish a clear airway. Administer intravenously nikethamide (coramine) in 10-
millilitre doses of a 25 per cent solution at intervals of fifteen to thirty _ minutes until
reflexes return. Instead" of this give intravenous injections of 6 to 12 milligrammes of
picrotoxin in a 0.2 per cent aqueous or normal saline solution every fifteen or thirty
minutes. Picrotoxin is a powerful stimulant of the respiratory centre in the medulla
and is regarded as a very effective remedy in counteracting the coma of acute barbi-
turate poisoning, but owing to its poisonous effects it must be used very cautiously, and
must be stopped when twitchings of the facial muscles are observed.
Inject intravenously 10 milligrammes of amphetamine sulphate in 1 cc. of isotonic
saline solution, and repeat it in 20 -milligramme doses every thirty minutes. It is con-
sidered as a useful adjunct to picrotoxin, particularly when the latter has produced
twitchings of the facial muscles. It shortens the duration of coma. A new barbiturate
antagonist called "NP13" (B B -methylethylglutarimide) is also being tried.71
Inject 1/8 grain of strychnine hypodermically and repeat it after six hours, if
necessary. Give fluids liberally by the mouth or give normal saline with 5 per cent
glucose by the rectum or by the intravenous route to promote diuresis and hasten
excretion. Catheterize the bladder at frequent intervals. Perform lumbar puncture and
allow the cerebro -spinal fluid to escape until the rate of flow — drop by drop — is almost
normal. Start artificial respiration with inhalation of oxygen at high tension, if neces-
sary. To counteract shock and low blood pressure give 1-norepinephrine (Nor.
Adrenaline, Unichem, 2 mg. in 2 cc.) diluted with 500 cc. of 5 per cent glucose in saline
intravenously. The rate of flow is adjusted and maintained according to the desired
rise in blood pressure — a constant watch has to be kept.
If coma is continued for a long time, feed the patient with milk and glucose by the
stomach tube, and give injections of penicillin to prevent pneumonia or lung abscess.
Post-mortem Appearances. — Externally, there is cyanosis. Internally, the mucous
membrane of the alimentary canal is congested. The kidneys show degeneration of the
convoluted tubules. The lungs are congested and oedematous and are usually in a
pneumonic condition. The other organs are congested.
Besides the stomach, liver, spleen and kidneys, the brain should be preserved for
chemical analysis, as veronal is is retained in the brain.
Chemical Analysis.— 1. A few drops of Millon's reagent in a small amount of warm
water added to a solution of veronal gives a white, gelatinous precipitate, insoluble in
excess of the reagent.
2. Pure veronal melts at 191 °C.
3. A solution of veronal is rendered alkaline by adding a drop or two of ammonia,
and then a few drops of an alcoholic solution of cobalt nitrate are added. A violet colour
is produced.
4. A small piece of caustic soda is added to veronal and fused. Ammonia is
evolved. The residue dissolved in water gives a blue colour with ferrous sulphate solu-
tion and a purple colour with copper sulphate solution.
Medico -Legal Points. — Veronal is a powerful hypnotic, and in medicinal doses it
produces quiet and refreshing sleep without any ill-effects. It is largely used by patients
as a remedy for insomnia without seeking medical advice. Richards T2 suggests that the
drug produces mental confusion and affects the memory so much that the patient does
not realize that he has already satisfied the need, and automatically repeats the dose at
intervals. The result is accidental poisoning from large doses. Sometimes, it has been
taken for suicidal purposes. In one case it was accidentally taken in mistake for
kamala.
Veronal should be prescribed with great caution in renal diseases. Constipation
must always be avoided when the drug is being administered so that the poisonous
symptoms may not develop It is slowly eliminated mostly -unchanged by the kidneys,
so that it may be found in the urine for the first four or five days, but has usually dis-
appeared before ten days have elapsed. It has a cumulative action, and may lead to
chronic poisoning if administered for a long time. There is also danger of possible
addiction from the prolonged daily use of drugs of the veronal group.
70. Davis, Brit. Med. Jour., Oct. 10, 16, 1909, p. 1154.
79 n -i* ^1^m?°n ^ iSt?1?J^,Alstead' Brit Med- Jour-> APril 23, 1955, p. 1023.
79 n - i,'
72. Bnt. Med. Jour., Vol. I, 1934, p. 331.